Provider Demographics
NPI:1669036919
Name:LEE, SUJIN SEVILLE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SUJIN
Middle Name:SEVILLE
Last Name:LEE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SEVILLE
Other - Middle Name:SUJIN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:560 RIVERSIDE DR STE A204
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4704
Practice Address - Country:US
Practice Address - Phone:443-358-6193
Practice Address - Fax:443-358-6197
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC11467101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid